Singers must understand how to maintain their vocal and overall health in order to keep vocal production at the high levels required of them. In order to achieve this understanding, singers need in-depth knowledge of the anatomic and physiologic function of the complete vocal instrument, a pedagogically well-trained voice teacher, and the knowledge that they can reach out to a team of voice professionals (voice teacher, otolaryngologist, speech-language pathologist, and possibly others) who understand vocal technique and pedagogy as well as voice science and medicine. It is particularly important for aspiring singers to know they have a professional team ready and appropriately trained to help when vocal difficulties arise. The aspiring singer’s trust in this team of professionals must be established at the earliest levels of vocal training. If an aspiring singer is afraid to seek help from the voice teacher, otolaryngologist, and/or speech-language pathologist, valuable time will be lost in vocal development, damage to the vocal instrument may occur, and the aspiring singer may decide to choose another career path. It is imperative that speech-language pathologists and otolaryngologists have some training in vocal pedagogy if they wish to accept singers or aspiring singers as clients, and that voice teachers have a functional understanding of voice medicine and voice science. Ignorance is the quickest path to voice disorders for the aspiring singer.

I wrote Vocal Technique – A Physiologic Approach with the intention of appropriately educating and providing a strong foundation for aspiring undergraduate singers, whether their desire was to enjoy singing as amateurs, or perform as professional singers. In my teaching of undergraduate students, I found these young singers frequently able to produce very beautiful vocal sounds, but having little or no knowledge regarding how their vocal instrument functions when speaking and singing. Most of these singers seemed to have no idea what to do or whom to turn to when their voices were not functioning well. In addition to having a clear concept and understanding of the anatomy and physiology of the vocal instrument, they need to understand how to maintain that instrument on a daily basis; i.e. vocal hygiene, breath management, vocal exercises, careful attention to speaking voice production, and determining what might be detrimental to maintaining healthy vocal folds and bodies. I use Vocal Technique – A Physiologic Approach to teach undergraduate voice classes, initial voice lessons, and again in the vocal pedagogy course in the senior year. I find that students who fully understand the information presented within the book progress much more quickly in the voice studio, and I rarely find them in vocal distress.

Excellent singing requires appropriate posture, refined breath management skills, efficient phonation and resonation techniques as well as the ability to articulate in multiple languages without disturbing the vocal production. Professional classical singing requires perfect phonation; i.e. a clear and resonant tone quality, the ability to create a variety of tone colors, excellent dynamic control, accurate pitch, and the ability to infuse the vocal tone with many appropriate emotions. This means the aspiring singer must have the discipline and dedication to become a vocal athlete with the creativity and imagination of the best professional actor. Learning to sing well enough to perform for the public requires much more than the average person can even imagine. Singers cannot afford to be ignorant about any aspect of their profession if they are to be successful.

There are issues beyond vocal technique that can cause a very well-trained singer to have difficulty with his or her voice – respiratory infection, acid reflux, allergies, inability to “support” the voice appropriately because of bodily injury or illness, interruption in sleep pattern, stress, aging, dehydration, fatigue, and many more. A singer must know intimately his or her voice and how it functions when healthy so that when it is not functioning normally, he/she is fully aware and comfortable reaching out for support from the appropriate professional. A voice teacher can be of great assistance in many cases, but sometimes a singer needs to see a laryngologist, a speech-language pathologist, or a vocal specialist for proper diagnosis and treatment. The demands of professional singing necessitate excellent health, physical conditioning, and careful use of the speaking voice as well as the singing voice, so the aspiring singer must learn how to maintain his or her instrument early in the learning process.

I posed the following question, among others, to 35 undergraduate and amateur singers participating in a choral ensemble and/or a freshman level voice class: “Do you think singers, in general, are reluctant to see an otolaryngologist (ENT) or a speech-language pathologist (SLP) for problems with their voices? 16 responded “yes,” 18 responded “no,” and one did not answer. Of the 16 who responded that singers are indeed reluctant, three had actually seen an ENT or an SLP for a vocal issue. One singer who said she had not seen an ENT or SLP wrote about having “muscle tension dysphonia,” which would seem to indicate that she actually had seen an ENT or an SLP for diagnosis, but did not want to acknowledge this visit. Another respondent wrote that he had “strain and discomfort when singing,” but had never seen an ENT or SLP. Of the respondents who answered that singers are not reluctant to see an ENT or SLP, only two had seen an ENT or SLP, while eight of the respondents made the following statements regarding their own vocal health: “trouble with speaking voice,” “lost voice completely,” “voice hurts when I sing,” “belting created vocal problems,” “laryngitis due to asthma, allergies and bronchitis,” and “unresolved tinnitus, causing problems with pitch matching.” It follows that these singers might have been helped by a laryngologist or speech-language pathologist, but chose not to reach out to make an appointment.

When asked why an aspiring singer might be reluctant to see an ENT or SLP, the respondents made the following statements: “Singers think the problem is fixable by themselves,” “Fear of being told that there is irreversible vocal damage,” “It can be seen as embarrassing or you don’t want to admit you have a problem,” “Some singers simply resign themselves to discomfort or stop singing altogether,” “Singers feel they can resolve issues themselves by rest and homeopathic methods,” “They don’t want to admit there’s a problem because of the competitive nature of auditions. . . ,” “Perception is the ENT does not care about solving vocal problems for amateur singers,” “It is hard for a singer to admit there is something wrong with their vocal mechanism,” “Singers assume a referral means the voice is bad/sounds bad.”

When asked the same question, two professional singer/voice teachers responded with these comments: “I feel strongly that singers, myself included, are afraid to hear that something may be wrong. I also think that singing is a very expensive endeavor, and the thought of having to spend more money on doctor visits, or treatments, in addition to the cost of taking lessons, and coachings and paying tuition, or fees for applications and auditions, is daunting,” “The ENT I saw did not at all quell my fears. He told me that I had polyps (which I later found out was not the case) and suggested that I start coming in once or twice a week to help rebuild my voice. I had such an uneasy, unpleasant feeling about it that I went maybe twice. He did some pathetic vocal warm-ups that didn’t teach me anything and sent me to work with an SLP down the hall. Likewise, those exercises felt silly and I never felt reassured that this was going to make me better in any way.” This singer later went to a laryngologist and an SLP, both specifically trained to work with singers, and the results were entirely different as stated: “He was very kind, performing a gentle procedure to examine my vocal cords. He printed out photos and explained very thoroughly what I was looking at . . . the SLP was very kind as well. Her exercises were thoughtful, helpful and specific. She gave me reasoning behind every one of them. I actually followed through and did them every morning.” This singer went on to complete a Master of Music degree in vocal performance and to sing several opera roles successfully and is now a professional actress. Clearly, appropriate preparation of the otolaryngologist and speech-language pathologist in working with singers is important. There is no place for ignorance in the area of vocal technique and pedagogy for these professionals if they wish to take on singers as clients/patients.

Aspiring singers spend much one on one time with their voice teachers, perfecting their technique, and learning to trust the voice teacher implicitly. This trust is built up over time, and is an essential part of the training of the singer. “Singing teachers are not only music educators, they are also guardians of their students’ voices. An astute teacher does not just help prevent vocal difficulties by providing a student with expert, healthy singing technique; he/she also is often the first person to detect a vocal problem and is usually regarded by the student as the source of all knowledge about anything vocal.” (Heman-Ackah et al., 2008)

When a vocal issue arises, the voice teacher is usually the first to hear it in the singer’s voice, and the singer naturally trusts the voice teacher to “fix” the problem. When the teacher is unable to help the singer resolve the issue, the student begins to feel uncomfortable, worried, and even desperate. Their thinking follows the path – if my voice teacher can’t “fix” the problem, it can’t be fixed. I find that undergraduate student singers are particularly fearful of a referral to the laryngologist, even when I explain that this doctor is trained to diagnose and help resolve the vocal difficulty, not to criticize or place blame. I find that many singers find the idea of getting “scoped” to be quite frightening, even though I introduce this procedure in the freshman voice class, showing a video of a singer in the process. I want them to understand this is not painful and will help to diagnose the problem. Perhaps more importantly, for the aspiring undergraduate singer there is a clear social stigma attached to visiting a laryngologist, so if the singer does make an appointment, he or she will keep it a secret.

When the laryngologist refers a singer to an SLP, this seems to be even more difficult for the singer to accept. It says to the singer that it is his or her own fault that he/she has a vocal problem. If the SLP is not knowledgeable regarding vocal technique, and works with the singer as if he/she is the same as every other client who comes into the office for voice therapy, I will have a very difficult time convincing my student singer to continue with appointments as advised by the laryngologist. An SLP working with singers MUST have some training in vocal technique and vocal pedagogy and should be willing to work in ways that are familiar to the singer from voice studio work.

If there is a diagnosis of vocal nodules, even though the voice teacher may have suggested this might be the case, it is always a shock to the singer. The singer generally comes back to the studio depressed and feeling as though his or her singing life is over. Frequently, vocal nodules can be removed through careful vocalizing and establishment of healthy speaking and singing technique, but aspiring singers want an instant cure. Many will choose to do surgery, even when the laryngologist says it is not really necessary, so they can put this diagnosis in the past as quickly as possible. The singer does not want to consider the need to do preoperative speech therapy, surgery followed by vocal rest, postoperative speech therapy, and, finally, slowly bringing the voice back to the ability to sing with excellent technique. If the singer continues to speak incorrectly or without support the outcome, even after surgery, will not be good.

So, what I am proposing here is that voice teachers give their aspiring singers an excellent foundation in vocal technique – posture, breath management, phonation, resonation, etc., and carefully teach them about the anatomy and physiology of speaking and singing so they understand the importance of establishing an appropriate speaking pitch, not screaming at the college football game, not speaking over noise at the local club, singing music from the correct voice category, and so many other directives coming from the teacher. Voice teachers should insist that their students see videos such as the ones for which links are provided on the companion website for Vocal Technique – A Physiologic Approach, demonstrating the anatomic function of the larynx, lungs, diaphragm, and surrounding muscles. There are many YouTube videos demonstrating the use of the laryngoscope so that singers will know exactly what to expect when they visit the laryngologist’s office. In addition, voice teachers must coordinate with speech-language pathologists in their universities.

Speech-language pathologists need to understand and be able to demonstrate the diaphragmatic-costal breathing that a singer would use when projecting his/her voice in an opera house without a microphone. SLPs wishing to work with singers don’t need to be professional singers, but they must have a strong understanding of what is required for a singer to produce vocal tones worthy of the concert and opera stage, and it would help greatly for them to have formal training in vocal technique and pedagogy. I think this will change the way they interact with singers, and will certainly help gain the respect of their singer/clients. This should help to improve the communication between the two, and will keep the singer coming back to complete the therapy as prescribed. It will be important for SLPs working with singers to be able to use non-traditional forms of voice therapy that have a solid basis in anatomy and physiology. In order for speech therapy to be successful, the singer must be fully invested in the process, and the process must produce results quickly so the singer can get back to singing within a short period of time. Because singers have developed higher than normal levels of vocal stamina, and phonation skills, they expect to be treated differently as a client of an SLP. If they are not, they will not comply with prescribed treatment and probably will not complete therapy sessions or exercises at home.

It is equally important for the otolaryngologist to understand vocal technique and pedagogy when accepting a singer as a patient. If the otolaryngologist understands the hesitation and fear that is present when a singer makes an appointment to see him or her, this will help the singer remain calm and accept the diagnostic procedure and the diagnosis and prescribed treatment suggestions. “As vocal athletes, singers require special diagnostic and treatment consideration when voice difficulty develops because they must maintain higher-than-normal levels of phonatory agility, strength, and stamina to repeatedly execute complex laryngeal maneuvers” (Zeitels et al., 2002). It seems best that it is a laryngologist, specialized in the care of disorders of the voice and larynx, who treats a singer, but this is not always possible. When it is not possible, the otolaryngologist must take extra care to understand how the singer thinks and uses the voice.

In addition, there must be open and complete communication among the voice teacher, the speech-language pathologist, the laryngologist, and the singer in distress at all times. As the singer generally has full confidence in his or her voice teacher, but perhaps not as much in the SLP and/or laryngologist, this communication will help the voice teacher to motivate the singer to do the appropriate exercises. If the speech-language pathologist has a good understanding of vocal technique and the mindset of the aspiring singer, this will open the door to communication and success. In this regard, two of the professional singer/voice teacher respondents to my questionnaire stated:

“I have raised concerns about my inability to speak or sing, or concerns about how medicine will affect my singing voice. I understand that I don’t have a medical degree, but I do know that my voice is largely responsible for my income, and my emotional health. Concerns raised by patients should be addressed professionally and respectfully,”

Medical professionals and SLPs should “make sure you know how emotionally connected we are to our voices. Singing is our life, an echo of our very soul. For our singing voice to be in turmoil is as scary as telling a runner that they ruptured their Achilles’ tendon. It’s a very big deal.”

Let’s make sure we all do our part in fully educating aspiring singers to the best of our abilities. Every singer needs to be as educated as possible about the anatomic and physiologic function of the vocal instrument in addition to the many other areas of study. Understanding these concepts fully will allow every singer to seek out an outstanding voice teacher, and will certainly help to remove fear and anxiety about reaching out to the laryngologist, speech-language pathologist, or a voice specialist when vocal problems arise. If the voice teacher, laryngologist, speech-language pathologist, and other voice professionals understand voice science, medicine, technique, and pedagogy to an appropriate extent, and communicate clearly with one another when working with a singer in vocal distress, the outcome will surely be a good one. If we communicate well with one another on a regular basis, we cannot help but replace ignorance with knowledge for our singers, clients, patients, and ourselves.